Delivering a user-centred NHS virtual visit service during COVID

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Jack: Good afternoon and welcome to our fifth Made Tech Talks webinar, as a part of the Leeds Digital Festival 2020. Today’s topic is going to be “Delivering a user-centred NHS virtual visit service during COVID”. Our speakers today are: Adam Chrimes, Senior Developer at NHS Digital; our very own Jessica Nichols, Senior Delivery Manager here at Made Tech; Ian Roddis, Deputy CDIO at Kettering General Hospital NHS Foundation Trust. Our speakers’ Twitter handles can be found on the screen. We’ll be sharing these again at the end of the session, if you want to keep up to date with everything they’re up to.

Now, the way today is going to go is that it’s going to be a 45 minute presentation from when I hand over to our speakers, followed by a 15 minute Q&A at the end of the session. So if you have any questions for our speakers, please do make use of the Q&A function found at the bottom of your screen. We will endeavour to answer as many of your questions at the end of the session. Once the session has concluded, we will also be sending out feedback forms to all of our attendees. They take a minute to fill out, and they go a very long way to helping us improve our future events. We’ll also be providing some information on our next Made Tech webinar as well.

I should also mention there are there are subtitles available for this presentation. Information on how you can obtain those will be found in the chat function, and we’ll be displaying them throughout the presentation just in case you missed it on the way in. Last note – this session will be being recorded. And with that, I’m going to hand over to Jess. Jess, if you’d like to take it away for us.

Jess: Thanks Jack. So I’m going to start by casting our minds back to April. April was a while ago, but just so that we’re all on the same page about how bad COVID was, let’s just imagine for a moment that you’re struggling to breathe, you end up being sent to hospital, your personal items are taken away, you’re frightened and you’re told that you can’t see your family and your family can’t see you. You’re admitted into Intensive Care, your condition quickly deteriorates, and suddenly you’re scared of dying but no-one is allowed to see you. No-one is allowed to hold your hand, no-one is allowed to say goodbye, no-one is allowed to say “I love you.”

These were the critical conditions in which we found ourselves, in the midst of the COVID pandemic. All visits inside of wards were cancelled. The wards themselves were locked down. That meant that patients felt stuck and not able to see their loved ones. It also meant that, unfortunately, patients were dying alone, without their family there to say goodbye to them. The NHS staff were also completely overwhelmed – physically, psychologically and emotionally. So this webinar is a story about how we tried to help.

This was an incredibly challenging situation for the NHS and for the UK to find themselves in, but we tried to help by building an Open Source virtual visiting solution. This allowed video calls from anywhere in a hospital ward to a loved one anywhere in the world. It was provided at no additional cost to the patient themselves, and did not collect onerous amounts of personal information – so the impacts on things like privacy and governance was minimal – and ultimately meant that the NHS staff members were able to serve and help the patients that they had in front of them.

So, let’s recap. What did we actually do? So within 48 hours, we built an Alpha to get something into the hands of users very quickly. This Alpha was Open Source from the very beginning, utilising the best work that the NHS Digital service manual has – and we’ll talk about more about that in a bit. From the very start, this was focused on user needs. At some points of the project we had hourly feedback cycles with real NHS staff members on the front line, who were telling us – not only what it was like at that time inside a ward that was closed down, with patients dying around them – but also how we could help them, by perhaps different features or a different flow within the service.

We started off by rolling this out into one or two wards, then we went slightly further into multiple wards. After that point, we started tackling multiple hospitals, and then multiple NHS trusts – and Ian in a second will talk a bit more about that.

So, what does this what did the NHS ‘Book a virtual visit’ service achieve? I like to think about this in four buckets: Firstly is the technology side. As I mentioned previously, this was an Open Source piece of technology that facilitated crucial conversations between patients and their loved ones via video. We also managed to get this done, get an Alpha done and something out there within the first 48 hours, and we made sure that it was always user-led. We weren’t prioritising features because of say a requirement stock; we were prioritising features because we were hearing it first-hand from our users.

The second bucket I like to think about this is the metrics side. So far, the service has facilitated over 8000 video calls – that’s 8000 conversations between patients and their loved ones which might not have happened. The calls themselves average over an hour in length. This shows – to me and to the team who have worked on it – how critical these conversations are. These aren’t quick 15-minute catch-ups with somebody; these are in-depth emotional conversations. Six months after launch, we’re finding ourselves with about 40 visits per day. We were a bit worried that with wards opening up, before future possible waves of coronavirus or other pandemics in the future, we had thought that perhaps usage of this tool would just cease to exist. what we found was that it serves a real need, even with wards being open for visiting.

The third way I like to think about this is the scope of the project. So this ‘NHS book a virtual visit’ service is rolled out into six hospitals – that’s more than 50 wards across the NHS that have access to this. It’s proven that we can work in new Agile ways of working, both for frontline NHS staff, but also for the back office IT teams, which are the backbone in supporting hospitals, the patients and the NHS’s needs. It’s also allowed the NHS trusts which have rolled this out to be prepared for future pandemics or future scenarios in which visiting is not achievable.

The final bucket of which I like to think about this is outcomes. Ultimately we had happy users, both NHS staff members on the front line were happy, and also the patients themselves. What we see here is not a stock image; this is a real life photo taken of an NHS staff member inside of a hospital, using the NHS ‘Book a virtual visit’ service to facilitate a conversation between their siblings who were inside of the same hospital with COVID symptoms. Even within the same hospital, even being an NHS doctor, you weren’t allowed to communicate with each other in person. So you can see just the utter joy on this individual’s face. This really works!

So, before we dive into a little bit more about what we’ve done and how it’s impacted the likes of Kettering Hospital, I’d like to show you a bit of a live demo. Wish me luck! So what we see here, imagine this rendering on an iPad for a frontline NHS staff member, perhaps a ward nurse. They have their iPad or similar device, and they’re walking around the ward, and they can see the calls that are coming up today. So for example, we have a Paddington Bear talking with Cher later on today. That should be a really interesting conversation! This list screen allows NHS staff members on the front line, nurses in wards for example, to be able to see where the devices need to be at certain times, to facilitate these conversations. It also ensures that personal information isn’t shared where it’s not needed. For example, you don’t find out any more about this conversation that patient Marsha P Johnson is having with Diana Ross – again an amazing conversation! – unless you click into it or tap into it on an iPad, and then you’ll display it with some more information here.

So let’s go through the flow of booking a virtual visit. Before scheduling a visit, the NHS staff member is just prompted that there are a few pieces of information that they need to collect, prior to being able to schedule the visit. This is just to ensure and give a heads up to the NHS staff members that they’re able to have all of the information together to start a visit. So I’ll tap ‘start’ now. Next, we’re displayed with a fairly typical list screen. Let’s work through these. So we start with the patient’s name – let’s just say this is my name. Next we want the key contact name. In this setting a key contact is usually displayed on a patient’s records, and it’s their loved ones or their family or their friends or their partner – but the individual who the patient trusts most in the world. Let’s just say that’s ‘Laura’ for this example.

Next we utilise an integration with ‘Gov Notify’ – the government’s central notification service for all text messages, emails and letters. We’ve chosen not to integrate letters here because we didn’t feel like it needed it, but we have the ability to send a notification to this key contact – the patient’s loved one – via text message or email. For the sake of this demo, we’ll just send an email. The NHS staff member is then presented with the ability to book into the future. It defaults to today. Based on user feedback, we found that most of our calls onwards are scheduled either just before or just after the doctor’s rounds in the morning. This is a peak time for use of the service, so we’ve defaulted it to the current date. In terms of the time, again based on user feedback and analytics, we’ve been able to identify that most calls happen relatively quickly. If you put yourself in the shoes of a potential user of this service, you can imagine how at the time you might have a patient who’s perhaps just about to pass away, and they want to schedule that call relatively quickly with the patient’s family and loved ones at home. So we’ve defaulted it to 10 minutes in the future for the sake of this demo, that’s fine for us.

Next we have a ‘check your answers’ screen. This is a fairly standard screen within the NHS’s design standards, but it’s just an opportunity for the NHS staff member to check some details about the key contact – specifically things like the phone number, to make sure it’s not a six instead of a nine, and to ensure that the email address is indeed correct. Next we press ‘book visit’. After this has happened – again, as I mentioned previously, based on user feedback we found that a flurry of these is done on wards in the morning – so based on that feedback we built the server or feature to enable very quickly booking of another virtual visit that skips the first few steps of that cycle that you’ve just seen, to speed up and improve the workflow for an NHS staff member.

For the sake of this demo we’re just going to view virtual visits. As you see here, we now have a call starting in a few minutes time, and it’s between Jessica and Laura, and we have the correct information here. The NHS staff member can start, edit, rebook or cancel that visit. Originally we only had ‘start’, but based on user feedback the ability to edit (for example to move a patient between different wards), to rebook (for example to head off the fact that they might want calls in the future) and also cancel. So let’s start this visit. In terms of information governance, we don’t hold an onerous amount of data within this tool, so we just asked the NHS staff member before handing over the iPad or similar to the patients, to confirm a few critical pieces of information: that the person joining is indeed the person we expect it to be, that they can tell the NHS staff member the patient’s name that they’re expecting to talk to, and also give the patient’s date of birth, which is a fairly common piece of information for the correct person to know. I’m going to stop my video on Zoom quickly, so that it will appear on this screen, and then click ‘attend visit’ and then ‘join meeting’.

So, what you can see here – apart from myself and my amazing cat next to me – is what’s happened is once I click ‘start visit’ it sends a second text message or email notification to the key contact. This gives them a unique URL so that they can join. So once they do, here we go, and then we can wave and say hello. And again, this is an amazing face-to-face conversation that we can make full screen on an iPad perhaps if we need to, and then we can take the conversation anyway we wish. After the call is finished, thanks Laura, we click ‘end call’.

At this point, we found that the patient is often with an iPad or similar device, and they want to be able to hand it over. I’ll just start my video here again so you can see me. They hand the iPad or similar device back over to the NHS ward member or NHS nurse. That conversation typically – based on user feedback – has been ‘wow that was an amazing conversation’. It’s been perhaps the first time in a few days or a few weeks that that patient has been able to talk with the people who they love most in the world, and the most requested thing from a patient is to rebook that for the future. So what we did, based on that user feedback, is built this feature of ‘rebook another virtual visit’. So I’ll tap this quickly.

This pre-populates all of the fields that we saw earlier, and just defaulting to the next day at the same time so that the NHS staff member who’s incredibly busy – and we’re trying to improve their workflow – just needs to click ‘continue’, double-check that it is indeed the correct information and press ‘book a virtual visit’.

If I go back to the main list screen, if I go to ‘upcoming calls’ you can see that there’s a call in here, and there’s also a call with Richard Clooney. Given we’ve completed this call, if I go back to the screen, you can see that it’s very easily displayed to the end user this is indeed completed. And in 24 hours in the future of this call being completed, all personal information is removed from the service. Only the fact that the call happened is kept, and the length of the call is kept as an anonymised piece of data, to ensure that we know how useful this is for individual wards.

I’m going to log out of this service now, and show you briefly the admin console side that is used by the back-office IT teams. If I log in as a trust admin here you see real-life data from Kettering General Hospital Trust, you can see the number of booked visits they’ve done, the average visit time and the average visits per day, along with the average visits, average participation per visit – you can see here that it’s quite high, this shows how valuable this service is. If we go into the hospital themselves, Kettering has one hospital, but you can imagine perhaps an NHS trust, which if slightly larger would have multiple hospitals being listed down. You can then see the number of total awards and the number of booked visits. If Kettering were to build a new hospital perhaps, the admin staff, the IT back-office admin staff would be able to very easily add a new hospital and take it on from there.

We also integrated – fairly recently – the ability for a key contact. So, in the demo you just saw, that was my colleague Laura. When Laura had clicked ‘finish call’ or ‘end call’ at the bottom, they were displayed with an option to give feedback in the form of a survey. This will give us additional information and insight into perhaps why the call was taking place, or their views on the call itself – how useful that was for them. We also have the opportunity for an NHS Trust at a hospital-by-hospital basis, to input their support URLs. This is perhaps if they have a patient support service or PALS within their local hospital, they can direct the key contact or the loved one and their family to the correct amount of information.

So that’s it for the live demo. I’m going to take it over and pass it over to Ian, who’s going to talk about life at Kettering.

Ian: Thanks Jessica, and ‘life at Kettering’ sounds rather grand! Hopefully you can see my screen now, and whilst I don’t have a cat alongside me, I have virtually alongside me: Anna, one of our Chief Nursing Information Officers, and Amir – I’ve seen you on the list – who’s been our project manager to get us to where we are today. So, as mentioned, I’m Deputy Chief Digital Information Officer at Kettering, and started in March just before COVID, which is a curious time to join a local trust.

And so this photo – hopefully you can see in front of you, and please share if you can’t – was Kettering General Hospital main hospital on Easter weekend. You can see in those trolleys we’re delivering Easter eggs, and in front of me, our two volunteers, our Chief of Surgery and our Deputy Medical Director. At the time we didn’t know it but that was the peak of COVID, the Easter weekend. I think this was just before Sonia Patel – who at the time was the joint CIO for the London trusts – put out a tweet asking for help from companies to build an app in 48 hours, which is what Made Tech did. I think they spoke to her at 5.30am in the morning, and by nine had started work on the project. It was shortly after that, so I think that was about the 14th of April, and around the 18th I started talking via Twitter to Made Tech. And so this is, in part, the power of social media.

I didn’t know Made Tech at the time but within hours I was chatting to Luke Morton, the CTO of Made Tech – on a Saturday actually – and the important thing to note, even in COVID times, we were looking to innovate and looking for ways to meet needs which were rapidly emerging. The situations were new. We were looking to innovate, but we were also looking to be safe. And actually, from what I saw from this, it’s built on the work of the NHS Digital service manual, which we’ll talk about in a bit. It just felt right, and if things feel right, you know, it usually is.

So we brought the service into Kettering from starting in the London Trusts which were big hospitals. We’ve had over 8000 virtual visits – from the dashboard I think was it just in the high 700s at Kettering and growing. And these calls have been from patients to loved ones at home. Actually, wards have split from COVID positive to not COVID positive, so we’ve had calls between both of those wards – we don’t want any hospital-borne infection – and even allowing parents to talk to babies who’ve been separated due to risk of infection. And yes, as Jess mentioned, there were calls with patients who were at the end of their lives, and it gave the chance for folks still to talk to each other.

And it’s not just the patients, as just said, it’s the staff. If you’re a nurse, if you’re used to providing that care and you can’t do it, it’s a big burden of stress. And this is… it says there, “including emotional moments – a granddaughter playing a piece of music on the piano.”

And as Jess has demonstrated, we added some new features. The great thing about this work, it’s all in GitHub, it’s Open Source, anyone can develop it, anyone can fork it and add features to it. Actually it was Anna… Anna’s very excitable, aren’t you Anna? Sorry you’re not on camera to show how excitable you can be! …to rebook a virtual visit and to a book recurring slots. I like to think that’s KGH’s contribution to this service at the moment. And, as I said, when I wrote this, it was over 600, but now we’re over 700, and more than 50 minutes.

And one of the interesting things here is the Emergency Department. So A&E has always been open, but we don’t want additional people in the hospital, both for them, for our patients and for us. So as crazy as it sounds, as Jess mentioned, you might rock up to A&E without any of your own phones or your battery may run out. And so you’ve got a service here that you potentially could use.

And it’s obvious COVID isn’t going away and visitor restrictions will be with us for a while, not least because of social distancing. And so just some quotes from what patients and loved ones said – folks naturally worrying about their loved ones who are in the hospital, through virtual visiting could speak and see every day. And actually anywhere in the world, this is all web-based. There’s no additional charge, either to the hospital or to the patients or loved Ones.

We’re quite… not ‘keen’ it’s the wrong word, but we’re all on this call, I’m gonna say we’re all digitally literate; not everyone is. And particularly some of our most vulnerable. So you can’t assume everyone’s got a phone, everyone’s got a smartphone, everyone’s comfortable downloading an app when needing in COVID times. And as it says there, folks can talk for as long as they want on this service. Lifting spirits: So in hospitals, of course you look after physical wellbeing, but that mental wellbeing and anxiety is a really key thing to look after. So in terms of benefits, so obviously it enhances that emotional support and wellbeing. Patients contacting friends, families and carers wherever they are in the world. It empowers patients actually, so it gives them the ability to make contact with who they like, when they like, particularly if you don’t have a device with you in hospital. Improved patient experience: Patients have been very happy with the offering and the ability to connect at the touch of a button; and it enhances patient care – we can rebook visits, we can send notifications and ward staff can support them in that, which allows them to spend more time caring for patients and less time administrating virtual visits.

And this great work has only been possible through companies like Made Tech, but also building on the great success of the NHS Digital service manual. I should probably put a shout out and say – not only is Adam a great senior developer at NHS Digital, he was a great colleague when I worked in NHS Digital on the service manual. So I am now going to hand over to Adam, who should bump me off my screen sharing by sharing his own.

Adam: Thank you very much Ian and Jess for that great talk. So hi everyone, I’m Adam, a developer at NHS Digital and I’m going to be speaking a little bit about the NHS Digital service manual, and how it’s helping teams build services for the NHS during the coronavirus pandemic.

So, what is the NHS Digital service manual? It’s basically a collection of guidance and examples for building digital services for the NHS, and so it contains everything from how to write content which is accurate, which is clinically approved, and which can be understood by anyone, regardless of their reading ability or their first language. It also contains guidance on accessibility, how to make services work for everyone, because the NHS is for everyone, all our online products should be working for everybody. And it also contains a bit of guidance about reusable components and patterns that you can use in the user interfaces when building services.

So it came around from all the work we’ve done on the NHS website, which was recently… you might have known it as ‘NHS Choices’ – so it’s been tested with real users of the NHS website, and many teams have contributed to this guidance. And whilst it’s maintained by a team at NHS Digital, we rely quite heavily on the wider community contributing back their Findings. So the findings that Made Tech and Kettering are having will work its way back into the service manual and we’ll grow that guidance so other teams can learn and benefit from it.

So I’m going to show you a little bit of the design system which teams use to build user interfaces. It contains everything from our design principles – which underpin everything we do when it comes to design – so putting people at the heart of everything we do, being inclusive – as I said, the NHS is for everyone, so it should be usable by anyone under any circumstances. We should be designing for trust – the NHS brand is one of the most trusted brands in the world, so we don’t want to jeopardise that, and we should be designing things that are reliable and secure. And making things open – as you’ve seen today, the Made Tech work’s been made Open Source, and we’re sharing everything we’ve learned here right now.

It also contains guidance on styles, such as colour, so you’re not messing around trying to find what the right NHS blue is, because sometimes you see services they use just a different tint of blue, but that is a big part of our brand, the NHS blue is predominant everywhere. So you can come in here and find the exact colour code you need, you don’t need to be messing around. It also contains different reusable components and patterns, such as the header components which we’ve seen on a couple of the services today, including this one. You can simply take the code, you don’t have to worry about whether the NHS logo renders properly on a mobile device and making sure you’ve got the NHS blue. It allows teams to concentrate on specific problems that they’re having within their services. It also has a number of patterns on how to ask users for their NHS number, which is a common one we’re seeing during the coronavirus pandemic. It tells you what format they expect it to be inputted in, where people can find it.

As well as the work we’ve seen from Made Tech today, there’s also been a number of services come out the back of the NHS Digital. One for example here is to get an isolation note. This was stood up by a team at NHS Digital in less than a month in the peak of the coronavirus pandemic, and the idea was that users could come online to get an isolation note to prove that they didn’t need to go into the office when we were still expected to go into the office. It relieved a bit of the pressure on the front line, and as you can see it’s been used over 1.6 million times, so that’s a lot of people not going to their GP practices and having to require a doctor or potentially spreading the virus around GP practices.

Another example which I think is quite a big one at the minute is the coronavirus vaccine studies. So this again was a service that was built by a team at NHS Digital in record time. It’s quite a beasty one, but we’ve seen over 250,000 people registered for the service, with 10k thousand volunteers now being invited to join phase 3, which I’m very hopeful this will kind of lead on to a vaccine and we all can get back to our daily lives. And again, this is something that was built using the NHS Digital service manual. And the learnings that they found on some particularly difficult questions were feeding back to the wider service manual, and that’s something we’ll be featuring shortly.

As I said earlier, this stuff is managed by NHS Digital but we couldn’t do it without the wider community. So, as you can see here, it’s all kind of Open Source, so all our backlogs and issues are all public, so you don’t need to be a member of NHS Digital, you don’t need to work for a company or a supplier, you can be literally anyone. We’ve seen students contribute to this stuff – and when I say ‘contribute’ it’s not necessarily always code, it might be fixing some spelling mistakes on the website or feeding back from issues they found when using patient services. Here you’ve got an example of David contributing some findings that he made on the ERS – the electronic referral system – to look into expanding the header component which I’ve shown earlier, to show some patient details on clinical-facing systems.

And that’s everything from me. Like I said, it’s Open Source, so if you do want to get involved, even if you don’t work for the NHS, if you’re just technically minded, you can find us at that URL. And if you do have any questions feel free to reach out. We’ve got a public Slack channel, and I can be found on Twitter on that handle. And I’ll hand back over to Ian.

Ian: Thanks Adam. This is going remarkably well! Shouldn’t say that halfway through. So in terms of key takeaways, what we’ve learned and what we’ll be taking forward with this work: So for me, I used to work in NHS Digital, I’m now working in a trust – let’s call it the front line. Obviously I’m working with digital teams. COVID has helped us kind of – I’m going to say break apart some of the solidity you might have found in local trusts. And just as the COVID situation is changing, within a digital portfolio I think with all future trusts going forward, we obviously need to be able to deliver services rapidly, so create new services, change services, deliver a service rapidly to meet user needs.

We obviously need to be patient-led and not supplier-led – and in that I should say user-led. Just to break apart what I mean by supplier: So our ability to influence, for example, Microsoft in their use of Teams, is almost zero. I’m very happy with Teams, it’s actually a great product for a local trust, but I can’t influence it. Here I can influence it 100% – It’s code that is Open Source, based on user needs. We could change it tomorrow. And so, yeah, being patient-led. Not just for patients but also for staff. So staff on wards are very busy, they need to be, we need to give them services which make their job easier and makes their ability to focus on patients the main priority.

We do need to innovate in a trust. I think we need to work with, I’m going to call them ‘modern digital folks’ – that’s what I wrote there – and by that I mean suppliers like Made Tech, and I’m sure many of the folks on this call. This particular way of thinking, it’s a way of working exemplified in NHS Digital, exemplified in the government digital services and exemplified… if there are a bunch of folks from Leeds, from the Leeds digital scene.

We need to join things up. So we often talk about ‘interoperability and integration’ but often you don’t define what you mean by that. The NHS has many many systems within it. I think I look after something like 137 contracts, and they’re often of different applications. We need to build on national standards. Those national standards may be underlying schema or data standards, and we need to use those standards to join up different systems for the benefit of patients. We need to grow local skills. The type of staff you may find in local trust or that local trust needed five or ten years ago, are highly likely to be different going forward. Elsewhere, I’ve been involved in some robotic process automation work, and then maybe that’s time for another chat. But the type of skills you need to develop these services use research, coding, interoperability stuff, will be different going forward. We need to grow local skills, either in Kettering or potentially in the group model within which we work in Northamptonshire.

And I think we obviously need to build on the best of breed across the NHS. So there’s been things like global digital exemplars and so on, but I think just something more low-key or lo-fi where trusts share what they’re doing, where they share skills, and actually they’re building collaborative ways with folks like Made Tech with NHS Digital. And yeah, absolutely, building on the fantastic work like the NHS Digital service manual.

And so, I think passing back to Made Tech colleagues, we’re now at Q&A.

Jack: Brilliant. Thank you very much Ian, and thank you to our other two speakers, Adam and Jess, that was absolutely fantastic. If you guys are happy to, I will dive straight into our Q&A. Again, a reminder: if you have any other questions that you want answered, please make use of the Q&A function found at the bottom of your screen.

So, first question: “How did you get access to the hospitals? What were the challenges you faced when arranging and performing user research in a covert era, and how did you overcome them?”

Jess: That’s a great question. So due to the wards themselves being locked down at the time that we were doing this work, and the speed at which we were doing this work – so I mentioned that we got an alpha out in 48 hours. There wasn’t a kind of official rigorous use of research settings or kind of set-up there unfortunately. If we had more time, that would have absolutely been where we had invested that additional time. Given the 48 hours and the fact that wards themselves were closed, we weren’t able to physically enter the hospitals unless we were unfortunately patients in the back of an ambulance perhaps, which isn’t really the best setting for any user research to happen. So we set up, at times up to hourly conversations, with real users on the front line, on things like MS Teams or Google Meets or Zoom, to get the real first-hand feedback as to what was going on. I think that there were points where we were getting up to 10 pieces of feedback, that were very different and very rich in terms of what we could do with this, per day. Then the job became: how do we prioritise this work, and which will provide the most amount of value right now, today? – given the timelines were so short.

Jack: Thank you. Our next question is: “How can I get to use this service?”

Jess: That’s a great question. So the service is Open Source. The repository is on GitHub, so you can find it if you go to github.com/madetech – you should see it in the list there. If not, just Google or Bing “NHS book a virtual visit GitHub” – I’m sure you’ll be able to find it. If you are a NHS trust or somebody similar with technical skill sets, there’s no requirement to have any commercial conversations with Made Tech at all, you can just fork this repo and off you go. All of the documentation is there, we don’t withhold anything at all, and so you should be in a really good place. And if you’d like, please feel free to reach out to myself or any other Made Tech colleagues if you need some more support in rolling that out. Typically that takes about two weeks for us to do.

Jack: Excellent. Straight on to the next one: “What is the future development roadmap for Made Tech?”

Jess: Good question again. Wow, thanks for the questions everybody! So I think I’ll answer this question in two parts. I see the future roadmap for Made Tech working on this as an Open Source piece of software, or an Open Source service, for use in the NHS and for other settings too. So from that perspective we’re looking at shoring up perhaps how we share codes internally, and working out how we can smooth the onboarding process for new users. As I mentioned, at the moment it takes up to two weeks, and whilst that’s a very short cycle to get something inside of the NHS set up and working, we think we can do better than that. So we’re looking at that too. At the moment there’s a reliance on a single cloud provider in order to facilitate some of the inner workings, and we’re looking to expand that, so that if a specific trust has a reliance on cloud provider A or cloud provider B, that the service is able to be interoperable there. There’s also I guess, from Ian’s perspective, from trusts themselves.

Ian: So virtual is interesting in a hospital setting. This is all very new. Hospitals have been very hands-on for many years, and you’ve started to see some telephone consultations and so on. COVID absolutely blew that out of the water. This is about virtual visiting, there was another typed question… It’s not about virtual consultation, as in when you are having clinical consultations, but we are working on both. I think this was an exceptional response to COVID, but what is really interesting now is what becomes the new norm in the NHS.

So we as a trust are continuing to talk with Made Tech, and hopefully do more work, and it’s gonna be very much let’s see what the next few months bring, both for response to COVID but also how the NHS is changing. What does virtual mean? As the new norm, what percentage will remain virtual? Not for any cost-saving reasons or whatever, but for patient experience. Because it’s not just folks who can’t meet because of infection control, it helps people who live far away, who may have other mobility issues, who just can’t afford to visit once a week or twice a week or so on. So there’s lots of benefits to this, beyond managing infection control.

If I just move on to the next question around devices: So as a trust, Kettering has quite an aggressive digital program of activity, and so we already have a number of devices on wards. We take observations on devices, we use a CareConnect product to message and do handovers, so our clinical staff have got devices and had devices. But for this, there was a grant – I’m going to say from NHS England, it might have been NHSx or NHSi, there’s so many variants of NHS which help fund the purchase of hardware. I think we may have had 20 iPad devices as part of the national response. But in any case, as part of other patient experience matters, we had a number of android devices. So nothing was bought specifically for this purpose, but as part of both the national response and our journey to being digital, we have a number of devices, and we will increasingly have devices onwards.

Jess: Just to add to that briefly as well: In those first few days, when we were getting something into the hands of users via the alpha stage of this project, and given the fact it was the height of the pandemic, there were times where I remember having a conversation with somebody inside of an NHS trust about well perhaps because they couldn’t get their hands on COVID proof or infection control rated iPad cases, so they ended up – and this is how quick and rugged it was – they ended up putting iPads inside of large freezer bags. And we can look back on that and smile now, but at the time it was, this is what you needed to do in order to let the patient say goodbye to their families, or let their families say goodbye to the patient. It was a really critical time, and so now thankfully stock is back up and the NHS trust that we’ve worked with so far have infection control approved iPad cases or similar, and we can forget about the days of using freezer bags. But yeah, it’s a real mix.

Jack: Brilliant, thank you very much guys. Next question: “How is patient confidentiality considered whilst a virtual visit is taking place?”

Jess: Yes I think that’s again a bit twofold. So there’s there’s the setup of the call itself, so prior to the NHS staff member handing over the iPad or similar device to the patient, and they do have a brief conversation just to ensure that the person oining on the other end of the screen is in fact the person that we were intending that to be. And we found out by user feedback that that conversation is usually a few minutes, it doesn’t take long to do, and actually serves as a really useful primer, perhaps to set expectations about how long the conversation might happen and other such things like that.

On the call itself, it’s really dependent on the state of the patient themselves. If the patient is is able to hold the iPad and have the conversation themselves, what we found is that NHS staff members leave the device with them and go about their other duties and help save lives elsewhere. However, we do also find – and so therefore the conversation is confidential, given that they are on their own having that conversation, or as confidential as it would be in a normal hospital setting, to go in and have a conversation next to somebody’s bed. Perhaps they could use headphones or similar to increase that confidentiality. However, due to the service being used for patients in say end-of-life condition, they might be perhaps comatose and they’re not able to hold their own iPad. In that setting, what we found by user feedback is that the NHS staff members stay by their bedside and they angle the iPad or device in order so that the family member can interact in some degree. So for those conversations it would be less confidential. But we do see those fewer and far between as we learn more about this disease of COVID and how best to handle patients. So it’s a real mix.

Ian: And if we just add to that, one of the reasons why we wanted to move away from our main number of the commercial services is because if you’re passing devices, they may keep a trace of your number or your loved ones numbers. And so with this, there’s both an audit trail of what call has been made, there’s the safeguarding aspect that usually a clinical member of staff has supported it, and we think we’ve safeguarded against the risk of patient contact details, or loved ones contact details, being shared. And obviously as I would say with our Information Governance colleague, we’ve talked through IG issues and GDPR and DPIA type issues.

Jack: Excellent, next question: “What pre-existing relationship brought you into this collaboration with the hospitals?”

Jess: Great question. I think again the answer is twofold. Firstly, for this specific project, there was a request originally from Sonia Patel at London North West, who’s now Central NHSx. Hi Sonia, if you end up seeing this, it was great working with you! So that that request went out via Twitter. There’s an amazing community of like-minded individuals who love building services to help people, both inside of the NHS and across the wider government. So that’s where a lot of this relationship, or like that’s where the kind of call to action was found.

In terms of the wider pre-existing relationships, it’s really just all about, given the fact that the services, this specific service and other NHS services, are Open Source. There’s a lot of inherent trust that you build very quickly by Open-Sourcing your repository and saying – anybody in the world can take all this amazing work that we’ve worked on and go and help other people with that. And I think that attracts a certain type of individuals to be working on those sorts of projects, in order to help share and leave the UK in a slightly better place.

Jack: Lovely. “What were some of the main security concerns and how did you mitigate them?”

Jess: Yeah so there was, as Ian mentioned, there’s lots of conversations with the Information Governance or IG folks. There’s a GDPR angle to this as well of course. Fundamentally, in terms of a mindset of approaching how we developed this, at every opportunity we found ourselves in, we chose to remove data – so patient data or key contact data – from the system. So we didn’t keep stuff around in a database somewhere lingering. We didn’t run analytics on it, we didn’t use that for Facebook ads or for something else. This was very much a use once type service, and then the data was removed. So from the very early days we made sure that we weren’t keeping stuff for longer than the service needed to keep it for, aka actually facilitating the conversation happening. For example, if a call is scheduled for tomorrow, removing the data from the database today isn’t very helpful because then we don’t know who to send the text message to or the email to; but after that call is finished, there’s no reason for us to retain that information. So from a mindset perspective it was easy for us to take the decision to remove it as soon as we don’t need it.

Jack: Excellent thank you. Next question: “What’s coming up next for the service?”

Jess: I think we covered a bit of this before, but from the Made Tech perspective I think there’s a few things we’re looking at. Lots of techy geeky things like how do we make it work with different cloud providers and all of that great stuff. From an individual NHS Trust perspective, once we have rolled out, we fully hand over to them and their internal teams, or facilitate that in whatever way that is necessary or appropriate for us to do. And so from an individual trust perspective, they have full ownership of this. If they, for example, wanted the ability to have two text messages sent or another reminder sent, they can absolutely go and do that. And I think to me, that’s one of the main benefits of having this as an Open Source project, is that people are able to build on this and take this for whatever purposes that they want.

As a bit of an aside, we’ve had hospitals from across the world be getting in contact about this. So for example, there’s a hospital network in Brazil who’s currently suffering the highest number of COVID cases in the world, who are saying “We’re really struggling with a very similar thing. How can the service help?” and the answer is very much, if you have the internal bandwidth to do this, you can absolutely fork the repository and off you go. And hopefully that’s what they end up doing, but that wouldn’t be possible if this was not an Open Source project.

Jack: Brilliant, next question: “How did you train frontline NHS staff?”

Jess: I guess there’s a Kettering angle to this that I’m sure Ian wants to cover too, but from the initial days, we had what we called super users. These were individuals who had my personal phone number and we were talking multiple times per day. They then employed a ‘train the trainer’ model within wards, and what we found is that most wards, in at least in the hospitals that we’ve brought out to so far, usually run 10-12 hour shifts, so two or three groups of individuals per day that need training. Perhaps some people are on holiday, so we put in place a brief training programme, but actually I guess a learning is we thought it would be a very onerous task to train frontline NHS staff, you know, they’re super busy, their level of technology understanding can vary quite considerably. But given the easy-to-use nature, hopefully you saw some of that in the demo earlier, it is just a few taps on an iPad screen.

Ian: Just to add to that, ease of use obviously is key, but personalities really matter. So Amir, our project manager walking onto the wards; again, with Anna using the strength of her personality; many of the nurses in charge, the matrons. They’re strong personalities, you know, because of what they do. And so that direct engagement with folks on the ward, in a clinically safe way, was also a big way of getting buy-in.

In terms of ‘what next?’ – So Kettering is in a group model with Northampton General Hospital, and we’re talking to them. Northampton have a broader patient base, so it’ll be to see how take-up goes at Northampton.

Jack: Excellent. I think we have time for one more question: “If you had 48 hours to build this service, were you able to fully adhere to the NHS service standards?”

Jess: We were able to utilise the Open Source nature of what Adam showed you, very very quickly. So as we were rolling things out, we made sure that they adhered to those service standards. There were elements, perhaps some of the functionality you saw in terms of the re-book functionality for example, that wasn’t there in the first 48 hour alpha. And so as we were rolling out new pieces of functionality, we did make sure that they adhered to the amazing standards that the NHS have.

Ian: And I will just say one thing: So in COVID times there were certain restrictions that were changed or altered. One of them was ‘COPI’ – the care of patient information – and there’s something potentially here around I want to say progressive enhancement, Jessica, and so on. So there’s something at the back of this where building services in extremis to deliver a service is great; but just to reinforce some of the work that Adam and colleagues do – having the standards that you should aim to meet, and having folks who understand why that’s so important – is really important for the NHS. And in part, that’s why I was saying about suppliers. So there are some great suppliers of commercial software, which are fully accessible, which is fully responsive, which would meet a service standard; but there’s so many examples of software supplied by suppliers which would not, and this is much nearer the ‘would’.

So I want to use this an opportunity to reinforce the need for national standards in the NHS, the need for a service standard. If you’re familiar with work like Gov that NHS Digital are promoting, and structures that support those standards. That also help folks like Directors of Finance or CEOs of trusts – I mean not ours because ours are great, but other Directors of Finance and CEOs – they need to understand what a national service standard is for delivering digital services, and make sure that their trust supports it.

Jack: Excellent, well thank you all so much for your time today. I’m going to share my screen. That concludes our Q&A section of the presentation. So again, massive thank you to our speakers taking the time to speak to us today, and an even bigger thank you to our attendees who have taken the time to come and listen. As I mentioned at the beginning of the webinar, we will be sending out feedback forms to all of our attendees. We’d love to hear what you have to say. It goes a really long way to helping us improve our future events.

Coming up next, as part of Digital Leaders Week, we have Luke Morton, our very own Chief Technology Officer at Made Tech, and Andy Callow, the Chief Digital and Information Officer at Kettering General Hospital NHS Foundation Trust. They will be speaking on “Better patient outcomes, interoperability and collaboration: transforming the digital delivery process in healthcare” and that will be taking place on the 14th of October.

Please do keep in touch. All our speakers’ details and Twitter handles are on the screen now. If you didn’t get your questions answered by them during the Q&A or if you just want to keep up to date with all things Made Tech, our details are up on the screen. Also, please feel free to join the Service Manual community at ‘nhs-service-manual’ on Slack. And with that, I want to say have a great afternoon and thank you for coming. Take care.